Quality of care

[Pages:50]Quality of care

A PROCESS FOR MAKING STRATEGIC CHOICES IN HEALTH SYSTEMS

Quality of Care

A process for making strategic choices in health systems

WHO Library Cataloguing-in-Publication Data

Quality of care : a process for making strategic choices in health systems.

1.Quality assurance, Health care. 2.Health services administration. 3.Decision making. I. World Health Organization.

ISBN 92 4 156324 9 ISBN 978 92 4 156324 6

(NLM classification: W 84.1)

? World Health Organization 2006

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All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

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Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Structure of the document . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. Background and assumptions . . . . . . . . . . . . . . . . . . . . . . . . 3 Why a focus on quality now? . . . . . . . . . . . . . . . . . . . . . . . . . 3 Why a focus on health systems and decision-makers? . . . . . . . . . . . . 3 Improving quality and whole-system reform . . . . . . . . . . . . . . . . . 5 Policy-making and evidence . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2. Basic concepts of quality . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Definitions and the dimensions of quality . . . . . . . . . . . . . . . . . . 9 Roles and responsibilities in quality improvement . . . . . . . . . . . . . .10

3. A process for building a strategy for quality: choosing interventions . .13 An overview of the suggested process. . . . . . . . . . . . . . . . . . . . .13 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Element 1. Stakeholder involvement . . . . . . . . . . . . . . . . . . . .15 Element 2. Situational analysis . . . . . . . . . . . . . . . . . . . . . . .16 Element 3. Confirmation of health goals . . . . . . . . . . . . . . . . . .17 Building the strategy: Choosing interventions for quality . . . . . . . . . . .19 Element 4. Development of quality goals . . . . . . . . . . . . . . . . .19 Element 5. Choosing interventions for quality . . . . . . . . . . . . . . .20 Mapping the domains . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Linking the domains to the decision-making process . . . . . . . . . . .25 Deciding on interventions . . . . . . . . . . . . . . . . . . . . . . . . .26 Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Element 6. Implementation process . . . . . . . . . . . . . . . . . . . .28 Element 7. Monitoring progress . . . . . . . . . . . . . . . . . . . . . . .29

ANNEX A: A self-assessment questionnaire for detailed analysis of Element 5 of the decision-making process . . . . . . . . . . . . . . . . . . . . . . . . .31

ANNEX B: A matrix to map quality interventions by roles and responsibilities in a health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Acknowledgements

The World Health Organization (WHO) expresses appreciation to all those who contributed to the production of this document.

The authors and project team:

Rafael Bengoa and Rania Kawar, Department of Health System Policies and

Operations, WHO, Geneva

Peter Key, Dearden Consulting Limited, United Kingdom Sheila Leatherman, University of North Carolina, USA and Judge Business

School, University of Cambridge, United Kingdom

Rashad Massoud, Institute for Healthcare Improvement, Cambridge, MA, USA Pedro Saturno, University of Murcia, Spain.

The core technical group included Ahmed Abdul Latif, Michael Adelhardt, Rebecca Bailey, Venkatraman Chandra-Mouli, Katie Edwards, Andrei Issakov, Rolf Korte, Itziar Larizgoitia, Hernan Montenegro, Anselm Schneider, Paul Van Ostenberg, Martin Weber, and Stuart Whittaker.

Valuable input and advice were provided by Sandra Black, Alimata Diarra-Nama, Christine Dowse, Enrique Terol Garcia, Maimunah Hamid, Graham Harrison, Khaled Hassan, Dale Huntington, Tom Mboya Okeyo, Hugo Mercer, Henock Alois Mayombo Ngonyani, Sue Page, Zinta Podniece, Sarah Prendergast, Osama Samawi, Maria Santos Ichaso, Tin Tin Sint, Sangay Thinley, Naruo Uehara, Mukund Uplekar, Orlando Urroz, Guillermo Williams, and Jelka Zupan.

Administrative and secretarial support was provided by Margaret Inkoom and Melanie McCallum.

Editing by Creative Publications

Graphic design and layout: In?s (inis.ie)

v

Foreword

This document provides decision-makers and managers at country level with a systematic process which will allow them to design and implement effective interventions to promote quality in health systems.

Conceived as a capacity-building tool in health-care quality, this guide focuses particular attention on people who have a strategic responsibility for quality. The reason for this approach is the understanding that in most countries there is an enormous amount of local readiness and action for quality improvement but frequently this action is carried out in an insufficient policy and strategic environment.

Furthermore, the process suggested here will help managers and decisionmakers decide on which components of quality they wish to focus. In some countries, there may be more leverage for quality in reorganizing the delivery of care across settings, while in others it may be more appropriate to start with patientsafety activities. The intention, therefore, has been to keep the process simple and to avoid suggesting that `one size fits all' and that there are `magic bullets' for quality.

The guide also assumes that a common process of decision-making for policymakers has relevance for the vast majority of countries, regardless of their particular circumstances. This assumption is made on the grounds that a robust process of decision-making will take into account country-specific factors ? such as current resourcing, cultural sensitivity, affordability, and sustainability ? in determining which combination of quality interventions will deliver the best outcomes and benefits for a country. The principles of quality management are largely identical across all countries, as they build on optimal use of scarce resources, client orientation, and sound planning, as well as evidence for improved quality of services.

Despite these commonalities across all countries, capacity-building in low- and

middle-income countries has some specificities since it operates in a highly

dynamic development context. During past decades, support to low- and mid-

dle-income countries has been driven by a supplier mentality. The focus was

on the transfer of financial and physical resources and technology, with the

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